Hindawi Publishing CorporationCase Reports in Critical
CareVolume 2013, Article ID 832306, 3
pageshttp://dx.doi.org/10.1155/2013/832306Case ReportA 75-Year-Old
Female with Hemoptysis andRecurrent Respiratory InfectionsMary S.
Baker1and Khalil Diab21Pulmonary & Critical Care Medicine,
Division of Pulmonary, Allergy, Critical Care Medicine, and Sleep
Medicine,Indiana University School of Medicine, Gatch Clinical
Building, Room 260, 541 N. Clinical Dr., Indianapolis, IN
46202-5111, USA2Clinical Medicine, Division of Pulmonary, Allergy,
Critical Care Medicine, and Sleep Medicine, Indiana University
School of Medicine,550 N. University Boulevard, UH 4903,
Indianapolis, IN 46202, USACorrespondence should be addressed to
Khalil Diab; [email protected] 7 March 2013; Accepted 4 April
2013Academic Editors: C. Diez, M. Egi, and J. StarkopfCopyright
2013 M. S. Baker and K. Diab. Tis is an open access article
distributed under the Creative Commons AttributionLicense, which
permits unrestricted use, distribution, and reproduction in any
medium, provided the original work is properlycited.Tis paper
describes the case of a 75-year-old female who presented with
signifcant hemoptysis over a 710 day period. Shehad a history of a
lef lower lobectomy 10 years prior for a lung abscess. She
subsequently had multiple episodes of cough,fevers, and possible
pneumonia treated with multiple courses of Amoxicillin and
Amoxicillin/Clavulanate. Review of her chestCT upon presentation to
the hospital showed a large necrotic lingular infltrate, which had
been progressively increasing in sizeover at least one year.
Bronchoscopy showed a yellowish, sof round body in the superior
lingular subsegment. Endobronchial andtransbronchial biopsies
showed actinomyces species. Tis is a very interesting case of
indolent actinomycosis which we suspect hada very slow progressive
course secondary to the multiple courses of antibiotics that the
patient was treated with.1. Case ReportA75-year-oldfemale was
admittedfor further workupofhemoptysis.
Tehemoptysisstarted710dayspriortoadmissionandwasbright
redandsignifcant involume(ofen greater than half a cup). Te amount
increased theday prior to admission. She reported subjective fevers
asso-ciated with her symptoms. She underwent a bronchoscopyat
anoutsidehospital,
whichwasabortedduetodifusenonspecifcbleedinginthelefbronchial tree.
Shehadahistory of bronchiectasis and lef lower lobectomy in 2002for
lung abscess; culture data from that infection was notavailable to
us. Since the surgery in 2002, she
experiencedchroniccoughandfrequentrespiratoryinfectionstreatedwith
multiple rounds of antibiotics, usually Amoxicillin
orAmoxicillin/Clavulanate.On physical examination,the patient was
afebrile andnormotensive. Heart rate was 68 beats/minute,
respiratoryrate 29 breaths/minute, and oxygen saturation 98% on
roomair. Head and neck examination showed normal dentitionwith no
lymphadenopathy. Chest examination showed clearbreath sounds
bilaterally with decreased air entry in the leflower lobe.
Abdominal and cardiac exams were unremark-able.Pertinent laboratory
studies included an arterial bloodgas analysis,which showed pH
7.34/pCO275 mmHg/PO292 mmHg/bicarbonate 40.4 meq/L. Te chest
radiographshoweddecreasedlungvolume inthe lefbase andanextensive
lingular and possibly lefupper lobe infltrate. ChestCT is shown in
Figures 1(a) and 1(b). Review of her chestCT one year prior showed
the same lingular infltrate withasmallersize. Onbronchoscopy,
ayellowish, sofroundbody was identifed in the superior lingular
subsegment. Tisbody was not immediately recognized. It was removed
andsent for histologic analysis. Also, several endobronchial
andtransbronchial biopsies were obtained. Tere was
subsequentsignifcant and copious bleeding in the lingula, which
wastreated with intrabronchial epinephrine and
resolved.Pathologyfromtheretrievedyellowishbodyrevealedactinomyces
species. Bronchoscopic cultures did not revealthe diagnosis. Afer
the biopsy results were reported, the tho-racic surgery service was
consulted. Te patient subsequently2 Case Reports in Critical
Care(a) (b)Figure 1: (a) Chest CT with lung windows shows an
extensive dense lingular infltrate with scattered air pockets; (b)
chest CT with softissue cuts shows the same lingular infltrate with
extensive necrosis and scattered air pockets.underwent a lef
modifed Eloesser thoracoplasty. Postoper-atively, she did very
well. She had complete resolution of herhemoptysis. She also had
complete resolution of her chroniccough,
whichhadpersistedfortenyears. Shecompleteda four-week course of
high-dose penicillin G and is beingtreated with a six-month course
of oral amoxicillin. She iscurrently undergoing planning for a
rotational fap to fll inthe chest wall defect from the frst
surgery.2. DiscussionActinomycosisisararebut indolent
infectioncausedbyanaerobic gram-positive bacteria of the genus
actinomyces,with the most common pathogen being Actinomyces
israelii.When frst identifed, the bacteria was classifed as a
fungusbecause of its yellowor whitish mycotic-like appearance.
Tisis what was seen as a whitish body on the bronchoscopydescribed
above. Te bacteria make up the normal fora ofthe oropharynx and are
frequently the cause of infection inpatients with poor dentition.
Actinomyces infection resultsfromdisruption of mucosal surfaces and
can occur anywhereinthebody. Teclassicinfectioniscervical
diseasethatofen presents as a large mass on the jaw or neck. Te
peakincidenceof activeinfectionisreportedinthefourthorffhdecadesof
life. Malepredominanceexistsandmostinfections involve
immunocompetent hosts. Risk factorsinclude alcoholism and poor oral
hygiene. Actinomycosis ischaracterized by a pyogenic response with
necrosis and canlead to severe fbrosis [1, 2].Actinomycosis of the
respiratory tract ofen results fromaspiration or direct extension
of disease from the head orneck. Pulmonary involvement is noted in
about 15% of cases.Pulmonary actinomycosis may be complicated by
unusualbut signifcant hemoptysis due to parenchymal destructionas
actinomyces can extend across fssures and even invadethe chest
wall. Clinically, pulmonary actinomycosis presentslike a lung
abscess or a nonresolving pneumonia. Patientspresent with indolent
symptoms that evolve over weeks tomonths. Tey typically develop a
nonproductive cough andlow-grade fever, which progresses into a
productive coughthat is sometimes associated with hemoptysis. Ofen
they willcomplain of characteristic features of pulmonary
infection:fever, cough, sputum production, sometimes night
sweats,and weight loss. Chest wall involvement and bony
erosionarecommon. Teinfectioncanmimicmetastaticdiseasefrom lung
adenocarcinoma. An uncommon complication ofpulmonary actinomycosis
is the development of a sinus tractthat appears as a
bronchocutaneous fstula. Finally, at latestages, patients may
manifest clubbing, anemia, and weightloss [1, 2].Inour case,
webelievetheinfectionevolvedover aperiod of at least several years
(although we do not havemicrobiologicconfrmationof that), as we
were able toobtain old CT scans of the chest that showed a
progressivelyenlarging lingular necrotic area. Our patient had a
chronicproductive cough and low-grade fevers and was treated
forpneumonia with multiple rounds of antibiotics. We believethat
the antibiotics may have acted to slow the progression ofthis
indolent infection.Patients with indolent actinomyces infections
that evolvedoveraperiodof9monthstoseveral yearsareshowninTable
1.Diagnosis can be difcult as these bacteria are part ofthe normal
fora and are ofen difcult to culture. Tere arecurrently no
serologic tests that can be used for diagnosis.Bronchoscopy is ofen
not diagnostic unless endobronchialdiseaseispresent. Bronchial
washingsandbrushingsarenot helpful. Transbronchial or open lung
biopsies are ofeninorder tomakethediagnosis.
Withthepropensityofactinomycosis to mimic malignancy, diagnosis is
ofen madeafer surgical resection [3].Untreated infections will
ultimately result in death, but iftreatment is initiated early the
rates of cure are greater thanCase Reports in Critical Care 3Table
1: Indolent cases of actinomycosis.SourcePublicationyearAge
ornumberofpatientsSymptomsHospitalpresentationDiagnosisRadiologicfndingsTreatment
OutcomeReechaipichitkul et al. [5] 2005 41 yearsFevers
&hemopty-sis over
2yearsMassivehemoptysisHistopathologyExtensiveright upperlobe
infltrateEmergentright upperlobectomy,intravenousaugmentinfollowed
byamoxicillinHemoptysisresolvedMa et al. [6] 2009 66 yearsFevers
&productivecough over4 yearsIndolentsymptomsof fever
andcoughHistopathologyRight middlelobeinfltratesSurgicalresection
andantibioticsSymptomsresolvedDujneungkunakorn et
al.[7]199916patientsCough andhemopty-sis
mostcommon;meandurationofsymptoms:9 monthsIndolentsymptomsas
reportedHistopathologyMass-likeshadowingmostcommon(37%)Surgicalresection
in 8patients;antibiotics forallAll patientswho hadsurgicalresection
werecured; 20% ofantibiotic-onlygroup did notrespond90%. Prolonged
treatment is needed, most commonly withpenicillin as the drug of
choice. Usually a combination of highdoses of intravenous and oral
antibiotics is needed. Alter-native antimicrobial agents include
tetracyclines, macrolides,and chloramphenicol. Surgery is indicated
for bulky diseaseor necrotizing infections that have eroded through
tissue,vasculature, or parenchyma. Relapse is common, but
withtreatment, long-term prognosis is good. Te combination
ofsurgery plus antibiotics has been shown in small trials toprevent
relapse [3, 4].It islikelythepatient wassparedfulminant
invasivediseaseintoher chest wall bytheintermittent doses
ofamoxicillinshe received for her recurrent pneumonias,
whichpossibly served to suppress her actinomyces infection anddelay
her diagnosis.In conclusion, pulmonary involvement in
actinomycosiscan mimic the presentation of lung cancer and can
resultinmassivehemoptysisandlife-threateningdiseaseif lefunchecked.
Earlydetectionisimportant, butdiagnosisisdifculty; therefore, a
high level of suspicion is needed.Conflict of InterestsMary Baker,
MD, and Khalil Diab, MD, have no confict ofinterests to
report.AcknowledgmentTis case has not been presented at any
previous conferencesand has not been submitted to any other
journals.References[1]G. F. Mabeza and J. Macfarlane, Pulmonary
actinomycosis,European Respiratory Journal, vol. 21, no. 3, pp.
545551, 2003.[2]O. Yildiz and M. Doganay, Actinomycoses and
Nocardia pul-monary infections, Current Opinion in Pulmonary
Medicine,vol. 12, no. 3, pp. 228234, 2006.[3]M. S. Boudaya, H.
Smadhi, A. Marghli et al., Surgery in tho-racic actinomycosis,
Asian Cardiovascular & Toracic Annals,vol. 20, no. 3, pp.
314319, 2012.[4]J. Choi, W. J. Koh, T. S. Kim et al., Optimal
duration of IVand oral antibiotics in the treatment of thoracic
actinomycosis,Chest, vol. 128, no. 4, pp. 22112217, 2005.[5]W.
Reechaipichitkul, T. Napaprasit, A. Puapairoj, and S. Pratha-nee,
Pulmonary actinomycosis presenting withprolongedfever and massive
hemoptysis: a case report, Southeast AsianJournal of Tropical
Medicine and Public Health, vol. 36, no. 5,pp. 12681271, 2005.[6]N.
Ma, Z. G. Wen, Y. H. Li, andD. J. Cui, Acasereportof
pulmonaryactinomycosis andreviewof the literature,Zhonghua Jie He
He Hu Xi Za Zhi, vol. 32, no. 7, pp. 485488,2009.[7]T.
Dujneungkunakorn, P. Riantawan, and S. Tungsagunwattana,Pulmonary
actinomycosis: a study of 16 cases from CentralChest Hospital,
Journal of the Medical Association of Tailand,vol. 82, no. 6, pp.
531535, 1999.Submit your manuscripts athttp://www.hindawi.comStem
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